Healthcare Provider Details

I. General information

NPI: 1043490824
Provider Name (Legal Business Name): GROVES ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 HIGHWAY 100 S
ST LOUIS PARK MN
55416-2175
US

IV. Provider business mailing address

3200 HIGHWAY 100 S
ST LOUIS PARK MN
55416-2175
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-6377
  • Fax: 952-920-2068
Mailing address:
  • Phone: 952-920-6377
  • Fax: 952-920-2068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLP1736
License Number StateMN

VIII. Authorized Official

Name: JOHN ALEXANDER
Title or Position: HEAD
Credential: M.ED.
Phone: 952-915-4257